Carlsbad, CA, USA
N86CE
Cessna 560
Air traffic control cleared the flightcrew for the instrument landing system (ILS) approach to runway 24, which was 4,897 feet long. The flightcrew then reported that they had the runway in sight, cancelled their instrument flight rules (IFR) clearance, and executed a visual flight rules (VFR) approach in VFR conditions to the airport. The reported winds favored a landing toward the east, onto the opposite runway (runway 6). During the approach, after a query from the first officer, the captain indicated to the first officer that he was going to "...land to the east," consistent with the reported winds. However, the final approach and subsequent landing were made to runway 24, which produced a six-knot tailwind. During the approach sequence the captain maintained an airspeed that was approximately 30 knots higher than the correct airspeed for the aircraft's weight, resulting in the aircraft touching down about 1,500 feet further down the runway than normal, and much faster than normal. The captain then delayed the initiation of a go-around until the first officer asked if they were going around. Although the aircraft lifted off the runway surface prior to departing the paved overrun during the delayed go-around it impacted a localizer antenna platform, whose highest non-frangible structure was located approximately 304 feet past the end of the runway, and approximately two feet lower than the terrain at the departure end of the runway. The aircraft continued airborne as it flew over downsloping terrain for about 400 more feet before colliding with the terrain and a commercial storage building that was located at an elevation approximately 80 feet lower than the terrain at the end of the runway. The localizer antenna platform was located outside of the designated runway safety area, and met all applicable FAA siting requirements. The captain had type 2 diabetes, for which he took oral medication and monitored blood sugar levels. He did not reveal his history of diabetes to the FAA. The captain's post-accident toxicology testing was consistent with an elevated average blood sugar level over the previous several months; however, no medical records of the captain's treatment were available, and the investigation could not determine if the captain's diabetes or treatment were potentially factors in the accident. The captain of the accident flight was the sole owner of a corporation that was asked by the two owners of the accident airplane to manage the airplane for them under a Part 91 business flight operation. The two owners were not pilots and had no professional aviation experience, but they desired to be flown to major domestic airports so that they could transfer and travel internationally via commercial airlines. One of the two owners stated that the purpose of the accident flight was to fly a businessman to a meeting, and to also transport one of the owner's wives to visit family at the same destination. According to one of the owners, the businessman was interested in being a third owner in the accident airplane, so the owner permitted the businessman to fly. The owner also stated that the accident pilot told him that the passenger would pay for expenses directly related to the operation of the airplane for the flight (permitted under FAA Part 91 rules), and an "hourly fee" (prohibited under FAA Part 91 rules); however, no documentation was found to corroborate this statement for the accident flight or previous flights.
*** THIS REPORT WAS MODIFIED ON DECEMBER 18, 2007 ** HISTORY OF FLIGHT On January 24, 2006, approximately 0640 Pacific standard time, a Cessna Citation 560, N86CE, impacted the localizer antenna platform during an aborted landing (go-around) on runway 24 at McClellan-Palomar Airport, Carlsbad, California. The two airline transport pilots and their two passengers received fatal injuries, and the aircraft, which was owned by GOSHIP AIR, LLC, of Ketchum, Idaho, was destroyed by the impact sequence and the post crash fire. The flight, which was carried out under 14 CFR Part 91, departed Friedman Memorial Airport, Hailey, Idaho, at 0600 mountain standard time (MST), and was being operated under an instrument flight rules (IFR) flight plan. At the time of the accident, the crew had canceled their IFR flight plan, and were executing a Visual Flight Rules (VFR) approach to runway 24 in visual meteorological conditions. The owners (principles) of GOSHIP AIR, LLC, were two businessmen with no professional aviation experience. According to one of the two principals of GOSHIP AIR, LLC, the flight to Carlsbad was scheduled on the day prior to the flight as a result of a phone call from JAXAIR, LLC, which consisted of one individual who was a pilot and was hired to manage the accident airplane for GOSHIP AIR (see the "Additional Data and Information" for detailed information regarding GOSHIP AIR and JAXAIR), According to the GOSHIP AIR principal, during this phone call, he was advised that JAXAIR and a local businessman had discussed the possibility of using the accident airplane to fly that individual to Carlsbad for a scheduled business meeting in San Diego. Permission was granted, and the wife of the GOSHIP AIR principal, who desired to visit family members in Southern California, was added as a second passenger. JAXAIR then advised Sun Valley Aviation, the owners of the hangar where the aircraft was kept, that the aircraft should be made ready for a 0530 departure the next morning. According to Sun Valley Aviation, on the morning of the accident flight, the co-pilot arrived at the hangar at 0455, and proceeded to preflight the aircraft. The JAXAIR captain arrived at 0520, the business passenger at 0532, and the wife of the GOSHIP AIR principal arrived last at 0545. After the passengers were loaded, the aircraft was started using a ground power unit (GPU), and then it taxied for takeoff at 0555. Discussions with personnel at Sun Valley Aviation, and a review of their security camera videos did not reveal any unusual actions or activities on the part of the flight crew, nor any obvious anomaly associated with the aircraft. The aircraft departed Hailey at 0600 MST (0500 Pacific standard time), climbed to an en route altitude of flight level 380, and remained there until 0605 Pacific standard time (PST), when it was cleared by Los Angeles Center to descend to flight level 350. At the time the clearance was issued, the aircraft was approximately 170 nautical miles straight-line distance, at a bearing of 026 degrees magnetic from the destination airport (although longer by flight path). Two minutes later, at 0607, the aircraft was cleared down to flight level 310. Approximately six minutes later, at 0613, the crew was given a clearance of direct Thermal (TRM), direct ESCON intersection, direct Carlsbad, and also cleared down to flight level 280. Three minutes later, at 0616, the crew was cleared down to flight level 240, and three minutes after that (0619), they were cleared to descend to 16,000 feet. The aircraft reached 16,000 feet mean sea level (MSL) just after 0626, and about one minute later the crew was cleared down to 12,000 feet. The aircraft reached 12,000 feet between 0630 and 0631, and at 0631:11, the crew was cleared to fly direct to ESCON intersection, and to descend to 8,000 feet. They were also advised to expect the Instrument Landing System (ILS) approach to runway 24, and they were told that the ILS glideslope was unusable. Approximately one minute later, at 0632:39, the crew was cleared to descend and maintain 5,200 feet. Thirty seconds later, at 0633:09, the crew was cleared down to 3,500 feet, advised that they were five miles from ESCON intersection, and told to maintain 3,500 feet until they were established on the ILS for runway 24. At 0635:01 the crew was advised that the airport was at their 12 o'clock position at six and one-half miles, and they acknowledged that it was in sight. At 0635:07, the controller at Southern California (SOCAL) Approach Control advised the crew to contact the Palomar tower. About six seconds later, the controller told the crew to disregard the switch to tower, since it did not open for another 25 minutes. He then advised the crew to either cancel their IFR clearance with him (the controller), or to report a cancellation within five minutes after landing. At 0635:22, the crew advised the controller that they were canceling their IFR clearance and switching to frequency 118.6 (Polomar common traffic advisory frequency). A review of the descent profile revealed that at the time the crew leveled off at 16,000 feet, the groundspeed of the aircraft was approximately 350 knots. When the crew leveled at 12,000 feet, the groundspeed of the aircraft decreased to about 295 knots, and then increased to about 330 knots for about one minute, before momentarily decreasing to 280 knots. The groundspeed then increased again to about 300 knots, and remained there for about another minute. About 0634:30, as the aircraft was descending through an altitude of about 6,700 feet, the groundspeed began a relatively linear decrease that brought it from about 300 knots to approximately 150 knots in a period of about two minutes. At the beginning of this speed decrease, the aircraft was about 8.5 miles from the end of the runway, and approximately 3,200 feet above the ILS glideslope. At the end of this two-minute period, the aircraft was seven-tenths of a mile from the end of the runway, and according to the NTSB performance data profile, within the glideslope two-dot deviation limit. About four-tenths of a mile from the end of the runway, the flightcrew went below the two-dot deviation limit, decreased their rate of descent from the 3,000-4,000 feet per minute that they had maintained for the previous minute, to about 1,000 feet per minute, and then crossed the runway threshold at a groundspeed between 130 and 140 knots. This groundspeed equated to a calibrated airspeed of 124 to 134 knots, with a six-knot tailwind. According to the Cessna Aircraft Company, the recommended reference airspeed for the accident airplane under the known landing weight conditions was 101 knots (see the "Airplane Information" section for detailed information regarding the calculation of this recommended reference airspeed). A review of the Cockpit Voice Recorder (CVR) and the recorded air traffic control communication during the descent revealed that the fight crew acquired both the Automated Terminal Information Service (ATIS) airport information and the Automated Surface Observation System (ASOS) weather information about 0622. At that time, their descent was approaching flight level 220, and the winds at Palomar were reported from 040 degrees at six knots. At 0632:14, the First Officer stated, "I'll be off on one," and the Captain responded with "Okay." From 0632:20 until 0633:49 (about one minute and thirty seconds) the First Officer was communicating with Western Flight Services, primarily about transportation for the passengers, and the Captain was communicating with Approach Control. During that period, approach control advised the crew that they were five miles from ESCON, and instructed them to maintain 3,500 feet until established on the localizer, and that they were cleared for the ILS to runway 24. Then after a brief pause, the controller added "You gonna be able to get down okay?" The Captain responded to the controller's question with, "ah yeah, thank you," but he did not read back the clearance, and the First Officer told the Captain to, "say thirty-five hundred until established." The First Officer then went back to his communications with Western Flight Services, but the Captain did not read back the clearance. At 0633:53, about four seconds after completing his Western Flight Services communications, the First Officer asked the Captain to confirm that they had been cleared for the approach, and the Captain responded with, "That's what he said." About six seconds after asking the Captain to confirm that they had been cleared for the approach, the First Officer stated, "Is that the airport down there," and the Captain responded with, "yeah," followed by what sounded like a chuckle. About six seconds after the Captain's response, the First Officer asked the Captain if he wanted to use speed brakes, and the Captain responded, "No, I thought it would be a go-around, land to the east …" (A landing "to the east" would have placed the airplane in a position to land on runway 6, which would have been the opposite end of runway 24, and would have been into the reported wind direction). Almost immediately after that communication, a portion of the ASOS transmission is heard again, and the First Officer advised the Captain that the winds were from 040 degrees, which the Captain acknowledged. About 40 seconds after the First Officer gave the Captain the updated wind direction, the controller advised the crew that the airport was at their 12 o'clock position at six and one-half miles. The First Officer advised the controller that it was "in sight," and the controller responded by advising the crew that they could "use S-turns to get down." The First Officer then thanked the controller for that clearance. At that time, the aircraft was about 5.8 miles from the end of the runway, and descending through 5,000 feet. At 0635:20, there was an increase in CVR background noise, which according to the NTSB Vehicle Recorder Specialist Factual Report, was consistent with the extension of the landing gear. About 20 seconds later, after he had canceled the flight's IFR clearance with the controller, the First Officer told the Captain, "Okay, you got forty-nine hundred feet." The Captain responded with, "I know, I'm slowing down." To that the First Officer responded, "Alright." About five seconds after the First Officer's response to the Captain, a series of Enhanced Ground Proximity Warning System (EGPWS) alerts were recorded on the CVR. The series began with a number of intermittent "sink rate" alerts, and terminated about 20 seconds later with, "pull up, pull up, pull up, pull up, pull up, sink rate, sink rate, minimums, minimums, one hundred, sink rate, forty, thirty, sink rate". The series of alerts terminated at 0636:31, and, according to the NTSB Vehicle Recorder Specialist Factual Report, the sound of the landing gear contacting the runway occurred at 0636:52.8. Although the Captain had earlier indicated to the First Officer that he was going to "…land to the east," the approach and subsequent landing were made to runway 24. According to numerous witness statements and NTSB measurements based upon witness accounts and security camera video recordings, the aircraft's wheels did not contact the runway until it reached a point approximately 1,500 feet west of the runway 24 threshold. Then, according to many of the same witnesses, within one to two seconds after touchdown, both thrust reversers deployed, followed almost immediately by the loud engine noise that they normally associated with the power applied for thrust reverser operation. At that point, most of the witnesses who had initially started watching the aircraft because of what they perceived as its higher than normal approach speed (some called it "very fast", or "way too fast") turned their attention to other things. The witnesses that continued to look at the aircraft and/or listen to the sounds from its engines, said that it appeared normal to them when after a number of seconds the engine noise began to decrease as an aircraft slowed. The witnesses stated that they were surprised when they heard the engines spool-up (accelerate) again, and most of the witnesses assumed that meant the crew had aborted the landing and were initiating a go-around. Although a number of witnesses looked back toward the aircraft when its engines accelerated, their view was blocked by structures, parked vehicles and parked aircraft, and none reported actually seeing the aircraft depart the end of the runway. (No tire tracks were noted by investigators in the easily marked terrain off the departure end of the runway, indicating that the aircraft was airborne as it passed the runway overrun.) After passing the end of the runway, the aircraft continued another 304 feet, whereupon it impacted the non-frangible wooden platform upon which the localizer antenna array was sitting. According to the NTSB Vehicle Recorder Specialist Factual Report, at 0636:52.8, there was a sound recorded on the CVR consistent with one or more of the landing gear contacting the runway, followed one and two-tenths seconds later (0636:54.0) with two distinct clicks, followed by a significant increase in background noise. For approximately the next five seconds, there were no communications between the crew members, nor were there any significant changes in background noise. Then at 0636:58.9 the First Officer said, "Let's get on them." To which the Captain responded, "Yeah, I don't like this, we got, we got that (expletive) reverser over there." For the next six seconds, there were no inter-crew communications. At 0637:06.2, the First Officer asked twice, in rapid succession, if they were going around, and the Captain responded with, "Yeah, let's get (unintelligible word) out of here." At 0637:07.5, fourteen and seven-tenths seconds after the initial sound consistent with the gear contacting the runway, there was a significant decrease in background noise. Then, about two seconds later, the First Officer uttered two expletives, and about four seconds after that, there was a sound similar to a clunk and a sound similar to two thumps. Over the next three seconds there were a number of loud noises, with the final discernable, recorded sounds being an aural warning tone, followed by an electronic voice stating, "Bank Angle." The recording ended immediately thereafter. WRECKAGE AND IMPACT INFORMATION Examination of the accident site and wreckage by investigators revealed the following information: After traveling approximately 304 feet past the departure end of the runway, the aircraft impacted the center two sections of the non-frangible localizer antenna platform. The aircraft's nose wheel tire contacted the center platform support beam near its eastern end. The nose wheel fork, wheel, and tire assembly, which were sheared from the gear strut, were located on the ground near the west end of the platform central support beam. The majority of the center two ten-foot-wide sections of the platform and their supporting structure were torn out by the impact, and were scattered over a 40-foot wide by 115 -foot long path on the down slope to the west of the platform site. The outboard most 18 inches of the left wing impacted the steel platform access ladder approximately eight to eleven inches above the top surface of the platform. This section of the wing separated from the wing structure, and was found entangled in the ladder structure. Besides the nose wheel assembly and the left wing section, the only other aircraft structure found at the antenna site was the right main gear door. This door was located on the ground near the back (western) outboard end of the destroyed right platform center section. An outboard portion of a wing flap was found near the right (north) edge of the debris field approximately 70 feet beyond the east (initial impact) side of the platform. A portion of the right elevator was found near the center of the debris field about 150 feet past the east side of the platform. The outboard most 17 inches of the right wing were located near the right edge of the debris field approximately 220 feet beyond the initial impact point. A two-foot section of the left wing outboard lea
The captain's delayed decision to execute a balked landing (go-around) during the landing roll. Factors contributing to the accident include the captain's improper decision to land with a tailwind, his excessive airspeed on final approach, and his failure to attain a proper touchdown point during landing.
Source: NTSB Aviation Accident Database
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